Nursing Elites

1. What is the correct intervention for a patient experiencing anaphylaxis?

• A. Administer epinephrine
• B. Provide oxygen
• C. Monitor airway
• D. All of the above

Correct answer: D

Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.

2. A client has expressive aphasia following a stroke. Which of the following methods should be used when communicating with the client?

• A. Speak slowly
• B. Provide written instructions
• C. Use a picture board
• D. Write on a whiteboard

Correct answer: C

Rationale: When communicating with a client who has expressive aphasia, using a picture board is an effective method as it provides an alternative means of communication. Option A, speaking slowly, may not improve understanding for someone with expressive aphasia. Option B, providing written instructions, may also be challenging for individuals with this condition. Option D, writing on a whiteboard, may not be as helpful as using a picture board in facilitating communication for a client with expressive aphasia.

3. A client expresses doubt about the benefits of surgery. Which response by the nurse is most appropriate?

• A. Ask the client to explain why they believe the surgery won't help.
• B. Comment on the client's doubt regarding the procedure's benefits.
• C. Assure the client that everything will be fine.
• D. Acknowledge the client's uncertainty about the surgery.

Correct answer: D

Rationale: Option D is the most appropriate response as it acknowledges the client's expressed uncertainty about the surgery. By acknowledging the client's feelings, the nurse validates their concerns and opens the door for further discussion. This approach can help build trust and rapport with the client. Option A focuses more on seeking justification for the client's belief rather than addressing the underlying emotion. Option B, while acknowledging doubt, does not directly address the client's feelings. Option C, although well-intentioned, dismisses the client's concerns without exploring them further.

4. A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

• A. Ensure the injection produces a wheal on the skin
• B. Administer the injection in the client's thigh
• C. Use an intradermal needle for the injection
• D. Avoid touching the site after injection

Correct answer: A

Rationale: The correct answer is A: Ensure the injection produces a wheal on the skin. A wheal indicates that the PPD has been administered correctly, allowing for the proper interpretation of results. Administering the injection in the client's thigh (choice B) is not the recommended site for PPD administration; it should be administered intradermally. Using an 18-gauge needle (choice C) is unnecessary and not the standard practice for PPD administration as a smaller gauge needle is preferred for intradermal injections. Massaging the site after injection (choice D) can lead to inaccurate results by dispersing the solution, so it is important to avoid touching the site after the injection to prevent altering the test results.

5. A nurse is caring for a client post-op with a chest tube. What should the nurse check for regularly?

• A. Ensure the chest tube is periodically clamped
• B. Check for air leaks in the tubing
• C. Keep the client in a prone position for chest drainage
• D. Administer diuretics to prevent fluid buildup

Correct answer: B

Rationale: The correct answer is to check for air leaks in the tubing. Air leaks can compromise the function of the chest tube, leading to inadequate drainage and potentially causing complications for the client. Clamping the chest tube periodically is incorrect as it could lead to a buildup of fluid or air in the pleural space. Keeping the client in a prone position is not necessary for chest drainage, as the positioning may vary depending on the specific situation. Administering diuretics may not be directly related to monitoring the chest tube for proper function and is not a routine intervention for chest tube management post-op.

Similar Questions